Avoiding hysteria in war on A.I.D.S.

Press, 14 March 1987, Page 20

Avoiding hysteria in war on A.I.D.S.

The ‘Economist’ comments on the best way to fight A.I.D.S.

AN AMERICAN living in Munich was recently arrested for the crime of causing “bodily harm” to some people: he had slept with them knowing he had A.I.D.S. The West German State of Bavaria has since enacted measures requiring prostitutes, drug addicts and applicants for civil-service jobs to be tested for exposure to the A.I.D.S. virus, and requiring certain foreigners to prove that they are free of the virus before they are let into the state. The plague years have begun. They are going to be grim. Millions of people in central Africa, where the disease has been digging in for at least a decade, are now at risk. In the United States, the developed country where A.I.D.S. has spread furthest, around 31,000 people have caught the disease; 18,000 of them have already died. Another 170,000 or so have been infected with the virus and know it, and at least 1 millionmore Americans have been infected but do not know it.

Many people who have the virus in their blood have not yet come down with A.1.D.5.; those who do come down with it seem to be under an inescapable death sentence (see chart).. All countries will, at different times, be following America along these sickening curves. All will be paying dearly for it, and not just in human suffering: the cost of caring for each A.I.D.S. patient in America is $50,000-150,000 until he dies. Faced with these horrifying prospects, more Governments are likely to conclude, with Bavaria, that some individual rights have to give way before a huge menace to public health. The strange nature of A.1.D.5., however, means that they will often be wrong. The policies that will best contain A.I.D.S. are likely to be those which avoid the compulsory identification and isolation

of sick people — the methods that are appropriate for combating the typical plague. The typical plague is caused by a disease that is contagious (meaning it can be transmitted by casual contact). It is also marked by a high likelihood of infection as a result of contact, by a short span of time between exposure to the illness and either recovery or death, and by a coincidence of symptoms and infectiousness (meaning you know by looking at him when a person has smallpox and is likely to give it to you). All these things make the quarantining of victims the right response to a conventional plague. None of them exists with A.1.D.5..

First, A.I.D.S. is not contagious. It is communicable chiefly through sexual relations (largely heterosexual ones in central Africa, so far mainly homosexual ones in the West). Second, a single sexual contact can cause infection, but rarely seems to. Third, years usually pass between exposure to the virus and onset of illness, and another long period between illness and death. Fourth, during most of those intervening years victims look and feel perfectly healthy, even though they are by then both infectious and doomed.

Quarantines are tolerable when a disease spreads quickly and visibly, and when the victims being quarantined have to be isolated for no more than a few weeks. That is impossible with A.I.D.S. The human sexual impulse is immensely strong. An A.I.D.S. quarantine —

which is the only logical conclusion of compulsory State measures to identify and handle the victims — would have a chance of working only in a country that had the stomach for branding victims of the disease or putting them in concentration camps. Western countries don’t, yet. They must therefore design their policies on the assumption that the people carrying the virus will be moving freely among the population at large. The first signs of what unexpected conclusions this can lead to have now appeared. Compulsory testing for exposure to the virus sounds fine, but it is hard to see its point.

Testing ought to uncover as many as possible of those who have the virus, so that they can be given advice and (in some inadequate way) treatment, while uncovering as few as possible of those who are not infected — because too many people told they ’ are clear of A.I.D.S. tend to feel there is no better way to celebrate than promptly to have a lot of sex. Compulsion is the worst way to test the likely positives and to refrain from testing the likely negatives: homsexuals, drug addicts, and prostitutes will flee from compulsory tests, while those in low-risk groups will submit with shrugged shoulders. Conversely, the most recent American experience suggests that A.I.D.S. tests which are offered as a matter of course to people visiting venereal-disease, family-planning and drugs clinics will uncover a huge majority of those who are infected with A.I.D.S.

The people discovered in this way, and then given advice, do trend to react responsibly, by refraining from sex or by using condoms. They are told that they will then pick up fewer of the other sexual diseases that may

help speed the breakdown of the immune system. Even among this group, some will not refrain. They should be subject to the civil penalties of private (and perhaps State) lawsuits if they then infect others. But imprisonment of such people would in practice spread the disease more surely, though to a different population. The positive step Governments can take is prevention: to educate people in safer behaviour. This means encouraging less promiscuity and greater use of condoms and, unhappily, giving in-

travenous drug addicts the wherewithal of disposable syringes to pursue their habit. The negative policy is containment, and it must be coolly calculated. It has to seek the most effective way of slowing the spread of the disease consistent with the free circulation of A.I.D.S. victims in the society at large. The Western democracies have certain principles against the branding and segregation of people. They do not have to be sacrificed for A.I.D.S. to be fought. Copyright — The Economist